The 17-year-old trans boy died five days after he was found unresponsive in his room on mental health unit
A jury today revealed its conclusions following an inquest into the death at Prestwich Hospital of teenager Charlie Millers. Jurors determined Charlie had not intended to take his own life and identified failings in his care.
Charlie was found completely unconscious with injuries caused by a ligature. At the time, he was on a strict observation regime where he was supposed to be checked on every five minutes, heard the court. "Charlie should have been subject to a child protection plan as there would be regular meetings on a four weekly basis which would include Charlie and parents. The plan would have had a lead professional with oversight to drive the plan forward and ensure a robust plan was made and implemented and Charlie would be visited every 10 days by a social worker. The child protection plan would have ensured these actions were compulsory.
Charlie was being checked on every five minutes before his death, Greater Manchester Police told his inquest. But that major conclusion is not based on documentary evidence, the force admitted to coroner Joanne Kearsley. Questions were raised over whether Charlie should have been on constant, one-to-one observation. GMMH staff told the inquest that Charlie's condition may have been aggravated by having someone with him at all times, but the jury said that the absence of one-to-one care 'probably contributed to his death'.
On his hospital care, the jury determined: "On the 2nd December 2020, Pegasus ward was very unsettled that night, with staff facing many challenges and demands. Staffing levels were adequate and tasks were allocated at the commencement of the shift, but these weren't recorded until later. The allocations were fluid in nature due to the dynamic situation, with some staff put on alternative duties as the evening progressed and additional staff brought on.
"Due to Charlie's decreased haemoglobin levels, Charlie should have been increased to one-to-one observations but was not due to the nurse in charge being unaware. This probably contributed to his death." Charlie wanted to pursue medical intervention including starting puberty suppressing hormones. His family and school helped him with a referral to the Gender Identity Service for young people run by Tavistock and Portman NHS Trust, where he had been undergoing assessment.
Mental Health Old Trafford Prestwich
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